Last December 2017, Envision Healthcare Corporation paid an approximate $30 million to settle allegations for subsidiary EmCare doctors getting bonus payments for admitting patients to hospitals when it was not necessary.

History:

A subsidiary of Envision, EmCare is a provider of physician services to emergency departments, inpatient services for hospitals, acute care surgery, trauma and general surgery, women’s and children’s services, radiology / teleradiology programs and anesthesiology services. If you have ever been hospitalized, Radiology is one service which always seems to have someone other than the hospital billing you. One study of billing practices of 194 hospitals in which EmCare handled billing and was out-of-network; the average out-of-network billing rate was 62% higher than the national average of 26%. When EmCare’s billing was compared to that of a competitor TeamHealth, the latter’s billing in other hospitals was less and there was a smaller increase in out-of-network service billing.

If you remember a while back, Rusty and I would discuss the ongoing consolidation of hospitals, clinics, and pharmacies. The reasoning behind the consolidation was to have enough market clout when negotiating with insurance and Medicare. Having a larger presence and being able to set pricing nationally and regionally is a big factor in the rising cost of healthcare.

Envision is the biggest player in staffing ERs and Anesthesiology departments with 6% of the $41 billion emergency department and hospital-based physician staffing and 7% of the $20 billion anesthesiologist staffing. Two-thirds of all Emergency Departments (ED) do some type of outsourcing even if it is short term.

Present:

United Healthcare insurance is pitted against Envision’s practice of over pricing for it’s 25,000 emergency doctors, anesthesiologists and other hospital-based clinicians charge to patients and pass through. The disagreement over pricing and how it is paid for by insurance as billed by 3rd party providers will spill over into patients being billed more frequently for higher prices not accepted by insurance.

UnitedHealthcare’s 27 million privately insured patients could face expensive and unexpected doctor bills as of 2019 if Envision doctors become out-of-network for United Healthcare. According to the research group NORC at the University of Chicago more than half of Americans have received an unexpected medical bill. In another study by economists from the Federal Trade Commission in 2017, 1 in 5 emergency-room admissions resulted in a surprise out-of-network bill.

While the ACA increased the numbers of people insured, approximately 20% of people have problems paying medical bills largely because healthcare is still rising faster than most other costs and income. One source of increased costs has been the billing from out-of-network doctors billing patients utilizing in-network facilities such as hospital Emergency Departments. NEJM recently published a Yale Study by Zack Cooper, Ph.D., and Fiona Scott Morton, Ph.D. (Out-of-Network Emergency-Physician Bills — An Unwelcome Surprise) reported on the increased occurrence of surprise-billing for out-of-network services.

Patients typically do not choose to use out-of-networks doctors or facilities. They will choose an in-network facility and expect an in-network doctor(s) to care for them. Healthcare insurance expects its buyers to use in-network services or pay a penalty for not doing so. When one arrives at an in-network Emergency Department, they expect to be cared for by an in-network doctor. I have yet to hear a doctor on duty offering up he or she is not employed by the hospital but instead by a third party. The patient is not aware of in-network or out-of-network issues until they get the bill. The market place is not working for the customer and the doctor still gets the business regardless of the price and there is no competition from other facilities or in negotiated pricing due to having insurance. The third party employer knows this issue as well as the hospital. The only fool in the room is the patient waiting to be cared for and be used. Insurance will pay a portion of the cost or negotiate with the hospital for a price. The third party company employing the doctor may yet charge the patient for the balance of the costs associated with the doctor and at a higher percentage than normal. The uncovered and unexpected higher cost is the rub.

The authors of the Yale study analyzed the claim’s data of a large commercial insurance company insuring tens of millions of people, focusing on ED visits for people under 65 years of age, occurring between January 2014 and September 2015, and at hospitals registered with the American Hospital Association. They chose hospitals with over 500 ED visits and identified the Hospital Referral Region (HRR). Utilizing the breakdown criteria yielded “more than 2.2 million ED visits Broken in 294 of the 306 HRRs, covering all 50 states, and capturing more than $7 billion in spending.” The map of the United States (above) is a pictorial representation of the data.

Summarizing their finding and estimating cost impact, Yale: “of the 99.35% of ED visits occurring at in-network facilities, 22% involved out-of-network physicians. The greater than 1 in five ratio (22%) masks a significant geographic variation in surprise-billing occurrence to patients among HRRs. 89% and 62% of surprise-billing rates occur in McAllen, Texas and St. Petersburg, Florida as compared to Boulder, Colorado and South Bend, Indiana with the surprise-billing rate there near zero.”

Envision questions the validity of the study and blames United Healthcare for not paying the billing and claiming insurance is the problem. Insurance coverage is a problem; but, it is not of the same magnitude when one starts to look at the increase in costs of $1 trillion from 1996 to 2013 of which 50% was due solely to price increases.

Additional Costs?:

And yes there are “potential” extra costs for patients who are treated by an out-of-network ER physician or any out-of-network service. In one hospital I was in, Radiology was out of network as well as one surgeon. Both negotiated a rate with United Healthcare. Then too, this was written into the ESI policy. I had no choice in doing in-network as I came through the ER each time and was too ill to decide and/or go to another hospital.

In a Kaiser/New York Times Survey: Among the insured with problem medical bills, a quarter (26%) said they received unexpected claim denials and about a third (32%) say they received care from an out-of-network provider that their insurance wouldn’t cover. The out-of-network charges were a surprise for a large majority: 69 percent were unaware that the provider was not in their plan’s network when they received the care.

The same NEJM/Yale study which had looked ay frequency of surprise Out-of-Network Emergency-Physician Bills also looked at the costs of the bill and what was left over for patients to pay. On average, in-network emergency-physician claims were paid at 297% of Medicare rates. For reference in the Yale study, the authors used other medical disciplines as a benchmark. Orthopedists are paid at 178.6% of Medicare rates for knee replacements and internists are paid at 158.5% of Medicare rates for routine office visits. The Yale study showed out of-network emergency physicians charged an average of 798% of Medicare rates resulting in a calculated, potential, and additional cost for patients. The difference between the out-of-network emergency physician charge and 297% of the Medicare rate for the same services in the patient’s location could be billed for an average balance of $622.55 (unless their insurer paid the difference). It is also important to note that the potential balance bills can be extremely high; the maximum potential balance bill faced by a patient included in our data set was $19,603.

The suggested solution from the study was for states to require hospitals to sell a bundled ED care package that includes both facility and professional fees. In practice, that would mean that the hospital would negotiate prices for physician services with insurers and then apply these negotiated rates for certain designated specialties. The hospital would then be the buyer of physician services and the seller of combined physician and facility services. If physicians considered the hospital’s payment rates too low, they could choose to work at another hospital.

The hospital, doctors, and the insurance companies would compete for the best package to service the patients utilizing them. In the end, this is a stopgap measure until healthcare costs can be brought under control in a better manner.

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Michigan Electablog “Lame Duck Republican Majority at work in Michigan.”

• Accrued Sick Time: This was one of the proposals not allowed to go to the ballot. Why? Because if it passed and it would have, Repubs would have needed 2/3rds vote to overturn it. Instead they passed it before November 6th and now they are altering it by taking coverage responsibility from over 93% of Michigan’s firms. The threshold for exemption from the law was raised from 5 in the proposal to 50 in proposed legislation.

Out of 173,309 businesses in Michigan, 162,003 firms have fewer than 50 employees.

The amount of required leave will be cut in half from 72 to 36 hours. It will also take hundreds of hours of work to accrue a few days of leave as employees must work 40 hours to earn an hour of leave instead of the 30 established in the citizens-backed initiative.

• One Fair Wage: Michigan Senate Republicans voted to gut the minimum wage increase.

An amendment to the minimum wage increase passed earlier this year to deny voters a chance to vote on the citizens-backed initiative as a Proposal. Instead Senate Bill 1171 will add eight years to the deadline for increasing the minimum wage to $12, from 2022 to 2030. Tipped workers will be hurt the most with their pay capped at $4 an hour.

• Unions: In an effort to stop union leaders from being able to take paid leave to do their jobs as union stewards, etc. Republican Senator Marty Knollenberg introduced Senate Bill 796. Democratic Senator Vincent Gregory had this to say about the bill:

“Bills like this only serve one purpose, they are just another step in the systematic destruction of unions and workers’ rights. Union leave time arrangements are an efficient, cost-effective way to quickly resolve employee disputes, disciplinary issues and other matters, and they help not just workers but also management.”

• Puppy Mills: State legislators are working to protect puppy mills by ensuring they can continue to sell puppies to Michigan pet stores. House Bills 5916 and 5917 narrowly passed the Michigan House of Representatives last Thursday. It now goes to the Senate.

Ohio based Petland is the backer of these bills. Over 280 localities across the country have passed laws to prohibit the sale of puppies in pet stores, in order to protect animals and consumers. Petland has gone state-to-state lobbying lawmakers to shield the corporation from local regulation. In the past two years, they have failed in Florida, Georgia, Tennessee, and Illinois.

• Recycling aluminum and PET. District 17 House Representative Joseph Bellino:The bill removes aluminum and PET plastic away from community-based recycling systems. Rerouting these materials into local recycling programs would provide the boost recyclers need to sustain their programs and expand access to even more communities.”

What he fails to say is that ALL of the returned containers are now recycled. If the 1976 “Bottle Bill” is repealed, many of those returned containers would end up in landfills.

• Wetlands: Michigan State Republican Senator – Escanaba Tom Casperson proposed Senate Bill 1211 redefining which wetlands require state Department of Environmental Quality permission to modify or fill and doubling the size threshold at which regulation is required, from 5 acres to 10 acres.

Senate Bill 1211 would remove 70,000 wetlands statewide from protection totaling about a half-million acres. In most Michigan counties, it would include about half of their remaining wetlands. These wetlands, lakes and streams can be filled, dredged, and constructed on without a permit according to Tom Zimnicki, agriculture policy director for the Michigan Environmental Council.

• Mackinaw Tunnel: Lame Duck Republican Gov. Rick Snyder struck a tunnel agreement in October with the Canadian oil transport giant. The company would pay to build a $350-million tunnel beneath the straits that would encase a replacement pipeline to prevent a spill and allow the existing line to be decommissioned. The state is also expected to kick in $4.5 million in infrastructure costs for the tunnel.

To bypass environmental approvals and accelerate required land condemnation, Snyder wants the tunnel overseen and owned by the Mackinac Bridge Authority.

• Finally, Staff Allocations: Newly elected Democratic Senator Jeff Erwin revealed; Democratic members of the state Senate are given $129,700 plus two staff benefit packages (for two staff members.) Republican senators, in sharp contrast, are given $212,700 plus four staff benefit packages (for FOUR staff members). Democratic Senators get HALF of the staff and 61% of the financial resources of Republican Senators to run their offices.

These allocations are hold overs from the budgets created by outgoing Senate Majority Leader Arlan Meekhof. According to Irwin, legislative staff salaries range from $25,000-$75,000 with some exceptions. “As a minority member, I have learned, we can buy benefit packages from the Senate business office and squeeze a third staff member into that budget as long as the salaries are less than the total,” he told me.

I guess we will have to pound them into the ground again.

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At the CEPR blog, Beat the Press, Dean Baker and Jason Hickel are debating degrowth. Dean makes the excellent point that “claims about growth” from oil companies and politicians who oppose policies to restrict greenhouse gas emissions, “are just window dressing.” I also agree, however, with the first comment in response to Dean’s post that his point about window dressing could be taken much further.

I would add that economic growth is window dressing for what used to be referred to much more aggressively as “man’s triumph over nature” or the “control of nature.” Climate change deniers are more forthright about this connection between aggression and so-called growth: “Is “Strive on — the control of nature is won, not given” a controversial statement? What does it mean for science if it is?” asks Linnea Lueken at the Heartland Institute website.

If advances seem to come but are based on sentimentality, they are valueless; reaction must surely set in, and the advances had better never have been made. In sentimentality there is repressed or unconscious hate, and this repression is unhealthy. Sooner or later the hate turns up.

The most thorough discussion by Winnicott of his aversion to sentimentality is probably his 1939 article, “Aggression and its roots.” As it is only three paragraphs, I quote it in its entirety:

Finally, all aggression that is not denied, and for which personal responsibility can be accepted, is available to give strength to the work of reparation and restitution. At the back of all play, work, and art, is unconscious remorse about harm done in unconscious fantasy, and an unconscious desire to start putting things right.

Sentimentality contains an unconscious denial of the destructiveness underlying construction. It is withering to the developing child, and eventually it can make him need to show in direct form destructiveness which, in a less sentimental milieu, he could have conveyed indirectly by showing a desire to construct.

It is partly false to state that we ‘should provide opportunity for creative expression if we are to counter children’s destructive urges’. What is needed is an unsentimental attitude towards all productions, which means the appreciation not so much of talent as of the struggle behind all achievement, however small. For, apart from sensual love, no human manifestation of love is felt to be valuable that does not imply aggression acknowledged and harnessed.

The phantasied attacks on the mother follow two main lines: one is the predominantly oral impulse to suck dry, bite up, scoop out, and rob the mother’s body of its good contents.… The other line of attack derives from the anal and urethral impulses and implies expelling dangerous substances (excrements) out of the self and into the mother.… These excrements and bad parts of the self are meant not only to injure the object but also to control it and take possession of it.

Whether or not the infant has such unconscious aggressive fantasies about the mother’s body, Rex Tillerson, when he was CEO of Exxon, expressed similar, fully-conscious ones, “My philosophy is to make money. If I can drill and make money, then that’s what I want to do…” Robert White-Stevens, the corporate-designated nemesis of Rachel Carson following the publication of Silent Spring, exemplified the “control of nature” faction of science:

Miss Carson maintains that the balance of nature is a major force in the survival of man, whereas the modern chemist, the modern biologist and scientist, believes that man is steadily controlling nature.

White-Stevens’s vision of a “feeble creature” penetrating “every corner of the planet,”  and “contest[ing] the very laws and powers of Nature, herself,” could have been written as a Kleinian parody of the of the infantile arrogance of scientistic triumphalism:

Within the past 100 years, man has emerged from a feeble creature, virtually at the mercy of Nature and his environment, to become the only being which can penetrate every corner of the planet, communicate instantly to anywhere on earth, produce all the food, fiber, and shelter he needs, wherever he may need it, change the topography of his lands, the sea and the universe and prepare his voyage through the very arch of heaven into space itself.

This is the stuff that science is made of, and man has learned to use it. He cannot now go back; he has crossed his Rubicon and must advance into the future armed with the reason and the tools of his sciences, and in so doing will doubtless have to contest the very laws and powers of Nature herself. He has done this already by expanding his numbers far beyond her tolerance and by interrupting her laws of inheritance and survival. Now, he must go all the way, for he cannot but partially contest Nature. He has chosen to lead the way; he must take the responsibility upon himself.

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I get the alerts from Georgetown University Center for Children and Families weekly. The news much of the time is a reflection of the number of attacks on families and children who have lesser means to provide for healthcare themselves and depend upon Medicaid, ACA, and CHIPS for care. Since the election of Trump, McConnell and Ryan have been strutting around like the cocks on the walk demonstrating their machismo as they hold women, children and families hostage. Tough guys both and it is easy to threaten women and children.

For the first time in a decade, the number of uninsured children rose in the US. It is not much of a surprise to me as Republicans made it miserable for many in states which did not expand Medicaid, held CHIPS hostage, and threatened those applied to become citizens with denial if they used the nation’s healthcare.

Some Stats:

The Georgetown University Center for Children and Families:

– An estimated 276,000 more children were uninsured in 2017 than in 2016
– Three-quarters of the children who lost coverage between 2016 and 2017 live in non-expansion Medicaid coverage states for parents and low-income adults. The uninsured rates for children increased at almost triple the rate in non-expansion states compared to Medicaid expansion states.
– Nine states experienced statistically significant increases in their rate of uninsured children (SD, UT, TX, GA, SC, FL, OH, TN, MA).
– Texas is #1 again. Texas has the largest share of children without health coverage with more than one in five uninsured children in the U.S. residing in the state.
– States with larger American Indian/ Alaska Native populations tend to have higher uninsured rates for children than the national average.

Some History:

The funding for CHIP expired September 2017 and Republicans and Trump were playing cat and mouse with Democrats to extend it while they looked for ways to repeal the ACA or weaken it. As Joan Aker the Executive Director of the Center for Children and Families stated;

“The majority of uninsured children are already eligible for Medicaid or CHIP but are not currently enrolled. The name of the game here is to make sure that families are aware that their child has a path to coverage and that these kids get enrolled and stay enrolled.”

2017 was tumultuous for families dependent on Medicaid, CHIPs, and the ACA. Added to this was Trump’s hostility towards immigrant families. 25% of the children living in the United States have a parent who is an immigrant. For “mixed status” families, the fear of interacting with the government deters them from enrolling their children in government sponsored health coverage.

Conclusion:

Again, Joan Akers of the Center for Children and Families: “The nation is going backwards on insuring kids and it is likely to get worse.”

If we can get the Democrats in the House off their butt and start to represent “their constituents” as determined by the founding fathers who designed the House to represent the population, we may be able to put in place the foundation for future healthcare gains. Instead, we have the House Representatives playing the secret ballot game for House Speaker with a promise of a Dean Wormer double-secret ballot come January.

Under Trump, Number Of Uninsured Kids Rose For First Time This Decade

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Some humor, sarcasm, and disappointment.

JACKSON, MISSISSIPPI (The Borowitz Report)—Celebrating her election victory on Tuesday night, U.S. Senator Cindy Hyde-Smith said that, despite predictions that her state was ready to turn the page on its shameful past, “I never lost faith in Mississippi’s racists.”

“For weeks, we’ve been hearing national pundits say that Mississippi was ready to enter the twenty-first century,” Hyde-Smith told a crowd of supporters at her victory rally. “Tonight, with your help, we proved them wrong.”

Hyde-Smith said that, despite the media’s unearthing of a cavalcade of embarrassing comments and actions from her past, “I never doubted that, at the end of the day, the people of Mississippi would listen to the racist voices in their heads.”

Choking back tears, Hyde-Smith thanked her supporters for honoring Mississippi’s storied heritage of hatred and cruelty.

“Mississippi voters do not want to tear down the relics of our Confederate past,” she said. “As such a relic, I am eternally grateful.”

Exit polls showed that Hyde-Smith performed extremely well with voters who described themselves as bigots, and dominated among those who could not correctly spell “Mississippi.”

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Via Naked Capitalism and Lambert Strether:

And now abideth faith, hope, charity, these three; but the greatest of these is charity. –Corinthians 13:13

I posted this letter in Links, but I found I could expand on it. Spectrum Health Care’s letter to Hedda Martin speaks for itself, and for what our health care system has become under neoliberalism:

View image on Twitter

(The provenance: I started with AOC, who hat-tipped @DanRiffle, who linked to the original poster, @DanRadzikowski, quoted above. From Radzikowski’s thread, Hedda Martin: “This is me”; Martin’s GoFundMe, which was successful.) In this post, I’ll focus on two things: the intriguing backstory of Spectrum Health, the institution that denied Martin care until she could raise $10,000; and the weaknesses of GoFundMe as a solution. Before I get to the main part of the post, however, I’ll point out that Hedda Martin’s example is not exception…

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“On my wall, the colors on the maps are running”

Two years ago in a post entitled “Those who cannot see must feel”, I wrote:

The midterms were less than three weeks ago. Today Russia blocked the Kerch Strait, entrance to the Sea of Azov, effectively cutting off one of Ukraine’s ports. Ukraine says its navy is leaving port.

Between now and the end of 2019 is the most dangerous time, because any potential U.S. Foe will want to have any aggressive move be a fair accompli by the time the 2020 U.S. Elections are underway, let alone by the time a replacement for Trump can be inaugurated.
Good luck to us all.
[UPDATE: In case you’ve never heard it, here’s a link to the song.]

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Squanto — A Sad Thanksgiving Tale

I do not know how widely it is still taught or how, but when I was in elementary school in Ithaca, New York, I was taught about the “First Thanksgiving,” an event that happened in October, 1621 in Plymouth, Massachusetts, following a good harvest after the pilgrim colony, founded in 1620, had a hard year that saw half their population die (about 50 people, mostly of starvation).  It was a joint feast of the pilgrims with neighboring native Indians of the Pokenok tribe of the larger Wampanoag confederacy, led by Massasoit.  Crucial to the event was the assistance of Squanto, who taught the colonists how to grow corn (maize) and several other crops, including the use of fish for fertilizer, thus becoming the model of a “good Indian” who helped European, especially English, colonists in what would become the United States.  Much of this is true, although much is murky, such as what exactly was eaten aside from the deer brought by Massasoit’s people (probably not turkey).

The problem with the tale is more about what is left out rather than any outright falsehoods such as claims that what was eaten was what is now the standard set of dishes consumed at modern Thanksgiving dinners.  It was not even the first Thanksgiving on US soil, with previous ones in St. Augustine, Florida in 1585 and at Berkeley Plantation in Virginia in 1619, although both of these were simply major thanksgiving prayer sessions that did not involve either food or participation by neighboring native Indians, with indeed the Berkeley colony being completely wiped out by a native Indian attack in 1622 that also nearly wiped out the nearby Jamestown colony.  But there are more important things left out, with some of them disturbing and sad.

I found out about this stuff as I investigated this matter this year anticipating having Thanksgiving dinner with my niece, Erica Werner (who writes for the Washington Post), and the extended family of her husband, Bill, and their adorable two young daughters, Lucy and Olive.  As it was, both because there were too many grownups talking about this and that as well as them being clearly fully occupied with other matters, I did not get around to telling the tale there.  So I am telling it here, an addition to the old tale I and many others were taught in school at some time or other.

The most important detail is that the pilgrims were far from being the first English people to have dealings with the various tribes of the Wampanoag confederacy in what is now Massachusetts and Rhode Island (where Massasoit had his home base).  There were at least two previous attempts to start colonies in the area, in 1602 and 1605, both failed as the English insulted the natives and provoked them into hostilities, as well as failing to figure out how to produce food.  More egregious than just trying to impose Christianity and treating them as inferiors was that beyond these two failed efforts, English traders and explorers would regularly raid the tribes, outright stealing goods, and more importantly, kidnapping tribal members.  This is where the story of Squanto begins: he was kidnapped by a Captain Tom Hunt in 1614.

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I had heard about a video series on NPR’s Fresh Air regarding the origin and current issue with the concept of Fake News via Russia.  You can listen and read the interview of the author, Adam Ellick here. 

There are 3 videos of 15 to 17 minutes each.  The series is titled: Operation Infektion,  Russian Disinformation: From Cold War to Kanye You can watch them here.   It begins with the AID’s hoax that it was a biological weapon developed and released by the US Military and how the KGB planted it and got it to spread such that it was ultimately reported on a US national news broadcast.  This hoax still has it’s believers.

We learned about propaganda from our experience with Nazi Germany.  With the advent of the internet, propaganda has become a more effective and a less costly means of waging war.  Based on the reporting in the last episode of this series the US is vastly behind the curve when it comes to protecting our self from the harm it causes.

This really is an issue as large and significant as any of those most directly effecting us such as health care, climate change, income inequality.  Unfortunately unlike those whose effects are directly experienced, propaganda/fake news has a virtual reality cover.  Which leads to me to the question: What happens as humanity becomes more accustom to experiencing life via virtual reality than naturally?  I suspect we become more susceptible to the intent of propaganda/fake news.

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(Dan here…lifted from Robert’s Stochastic Thoughts)

by Robert Waldmann

I disagree with Jennifer Rubin

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